SURGICAL CLINICAL CASE

PRESENTATION
V. Keerthika
Final year,
Coimbatore Medical College

Guide:
Dr. T. Srinivasan,
Professor of Surgery,
Coimbatore Medical College and Hospital
 PATIENT DETAILS
• NAME : Mr. XXX
• AGE : 52 years
• SEX : Male
• OCCUPATION : Auto driver
• ADDRESS : Puliakulam, Cbe
 CHIEF COMPLAINTS
• Pain in the right foot since 3 months
 HISTORY OF PRESENTING ILLNESS
• Apparently normal 3 months back
• Then developed pain in the right foot
– Insidious in onset, Gradually progressive
– Continuous, severe pain, cramping type
– Aggravated on lying down (during sleep),
– Relieved by hanging leg down
• No history of pain in calf, thigh, gluteal region
• H/O blackish discoloration of right 4th toe 2
months back for which he underwent
disarticulation of right fourth toe at local
hospital
• H/O ulcer following disarticulation of toe 1
month back.
• H/O loss of sensation in right foot
• No H/O fainting, transient blackouts
• No H/O chest pain
• No H/O abdominal pain
• No H/O reduced urine output
• No H/O fever
• No H/O trauma
• No H/O swelling and redness over affected
part
• No H/O impotence
 PAST HISTORY
• H/O disarticulation of right fourth toe done 1
month back
• Not a known case of Diabetes mellitus,
hypertension, coronary artery disease and
cerebrovascular accident
• No H/O other past surgeries
 PERSONAL HISTORY
• Smoker for the last 20 years. One pack per day
• Not an alcoholic
• No H/O tobacco nut chewing, betel nut
chewing
• Takes mixed diet
• Normal bowel and bladder habits
 FAMILY HISTORY
• No relevant family history
 SUMMARY
• A 52 year old man, known smoker, presented
with rest pain in right foot for 3 months.
• Probably PVD of right foot with absence of
fourth toe.
 GENERAL EXAMINATION
• Patient is conscious and oriented
• Moderately built and nourished
• Afebrile
• No pallor
• Not icteric
• No clubbing
• No cyanosis
• No generalised lymphadenopathy
• No pedal edema
 VITALS
• Temperature: 98.5 F
• BP: 120/80 mm Hg in both arms, measured in
supine position.
• Pulse: 79 bpm, measured in right radial artery
in sitting posture
• RR: 14/min
 OTHER SYSTEMS EXAMINATION
• CVS: S1, S2 heard, no additional murmurs
• RS: Bilateral normal breath sounds heard. No
added sounds
• Abdomen: soft, non tender. Normal bowel
sounds heard.
 LOCAL EXAMINATION-INSPECTION OF
RIGHT FOOT
• Proper consent obtained
• Lower limbs are exposed completely from ASIS
to toes and examined
• Attitude of limb: hips and knees extended,
ankles dorsiflexed
• Right fourth toe is absent
 LOCAL EXAMINATION-INSPECTION OF
RIGHT FOOT
• An ulcer
– 3X1 cm size
– Over the right fourth digital
space
– Floor covered with slough
– Edges overhanging
– Margins irregular
– No discharge
– Surrounding skin is hyperpigmented
 LOCAL EXAMINATION-INSPECTION OF
RIGHT FOOT
• Skin shows thinning, loss of hair and
subcutaneous fat
• Nails show transverse ridges and are brittle
• Toe and ankle movements are normal
• Another 2X2 cm healed ulcer seen over the
dorsum of foot.
 LOCAL EXAMINATION-INSPECTION OF
RIGHT FOOT
• Buerger’s postural test:
– Gangrenous toe has already been disarticulated
indicating severe ischemia
• Left lower limb appears normal
• No engorged veins present.
 LOCAL EXAMINATION-PALPATION
• The right leg is cold when compared to the left
leg
• Skin temperature feels normal till the level of
ankle.
• Right fourth toe is absent
• An ulcer
– 3X1 cm size
– Over the right fourth digital space
– Floor covered with slough
– Edges sloping
– Margins regular
– No discharge
– Surrounding skin is pigmented
– The base of ulcer over the fourth digitial space is
formed by muscle and head of metatarsals.
 EXAMINATION OF PERIPHERAL PULSES
ARTERY RIGHT LEFT
Dorsalis pedis - ++
ATA - ++
PTA + ++
Popliteal ++ ++
Femoral ++ ++
Radial ++ ++
Ulnar ++ ++
Brachial ++ ++
Axillary ++ ++
Subclavian ++ ++
Superficial temporal ++ ++
Common carotid ++ ++
 SENSORY EXAMINATION

• Crude and fine touch, pain, temperature

sensation lost over right foot.
• Plantar reflex absent on right side
 MOTOR EXAMINATION
• Movement of ankle and toes normal
• Tone: normal
• Power: Normal
• Bulk: Normal
• Circumference measurements:
Right (cm) Left (cm)
Calf 35 35
Thigh 50 50
• Examination of left limb: Normal
• Examination of upper limbs: Normal
• Regional lymph node examination normal.
 SUMMARY
• A 52 year old man, auto driver, known smoker,
presented with rest pain in right foot for 3 months
• On examination, there is absence of fourth toe,
with absent dorsalis pedis pulse and anterior tibial
artery pulse, and feeble posterior tibial artery pulse.
Right foot skin shows ischemic changes.
• Provisional diagnosis: PVD of right foot with
disarticulation of right fourth toe (due to gangrene).
THANK YOU